Unethical promotion of rapid opiate detoxification under anaesthesia (RODA)

Brewer, Colin; Williams, J.B.; Rendueles, E Carreño; Garcia, J Bobes

doi:10.1016/s0140-6736(05)78171-x

Cited by 16 publications

(11 citation statements)

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“…A 'rapid' opiate detoxification (ROD) is simply one in which a full dose of NTX (or an implant) is given within 24 hours of starting [3] and can be performed under oral sedation, IVS or GA. 'Ultra-rapid opiate detox' (UROD) is no quicker than other rapid methods but was trademarked by the CITA company, who promoted UROD irresponsibly as a miracle cure [4]. They also criticized agonist maintenance.…”

Section: A 'Miracle Cure' Misunderstoodmentioning

confidence: 99%

“…Antagonist-precipitated withdrawal is now combined invariably with initiating oral or implanted naltrexone (NTX). RCTs show that supervised NTX is an effective adjunct to abstinence-based programmes [2] (as supervised disulfiram is in alcoholism), and that NTX implants/depot-injections are more effective than oral NTX or placebo implants.A 'rapid' opiate detoxification (ROD) is simply one in which a full dose of NTX (or an implant) is given within 24 hours of starting [3] and can be performed under oral sedation, IVS or GA. 'Ultra-rapid opiate detox' (UROD) is no quicker than other rapid methods but was trademarked by the CITA company, who promoted UROD irresponsibly as a miracle cure [4]. They also criticized agonist maintenance.…”

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A ‘Miracle Cure’ Misunderstood

Brewer

2012

Addiction

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References A 'MIRACLE CURE' MISUNDERSTOODKeith Humphreys' inclusion of 'ultra-rapid opiate detoxification' [1], among discredited 'miracle cures' for addiction, needs several important qualifications. The basic theory (using opiate antagonists to make withdrawal shorter, more successful and less unpleasant) was validated in several randomized controlled trials (RCTs) by respected academics in the 1970s and 1980s, all using oral sedation as well as specific antiwithdrawal drugs such as clonidine, to reduce discomfort. Using general anaesthesia (GA) or intravenous sedation (IVS) was a logical development, especially for patients who were difficult to sedate orally. Loimer and his entirely academic colleagues in Vienna were the first to use anaesthesia and regarded the procedure as merely making planned opiate withdrawal easier and more certain. Antagonist-precipitated withdrawal is now combined invariably with initiating oral or implanted naltrexone (NTX). RCTs show that supervised NTX is an effective adjunct to abstinence-based programmes [2] (as supervised disulfiram is in alcoholism), and that NTX implants/depot-injections are more effective than oral NTX or placebo implants.A 'rapid' opiate detoxification (ROD) is simply one in which a full dose of NTX (or an implant) is given within 24 hours of starting [3] and can be performed under oral sedation, IVS or GA. 'Ultra-rapid opiate detox' (UROD) is no quicker than other rapid methods but was trademarked by the CITA company, who promoted UROD irresponsibly as a miracle cure [4]. They also criticized agonist maintenance. In Britain, ROD acquired a bad reputation when a UROD patient died in unsupervised and thus still mysterious circumstances in a CITA clinic. However, in several other centres, using a variety of rapid or accelerated techniques, hundreds or even thousands of patients have had ROD followed by depot NTX with little detoxification morbidity, no deaths and 3-year outcomes that can compare with agonist maintenance. Declarations of interestThe Stapleford Centre is a private clinic and provides both agonist-and antagonist-based treatments for opiate dependence. It does not currently conduct rapid detoxifications.

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Section: A 'Miracle Cure' Misunderstoodmentioning

confidence: 99%

mentioning

confidence: 99%

A ‘Miracle Cure’ Misunderstood

Brewer

2012

Addiction

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“…There may also be memories of the way in which, during the late 1990s, the Spanish-Israeli CITA group employed intensive PR techniques to promote rapid opiate detoxification and oral NTX in Australia as something close to a miracle cure. 40 They failed, partly because of some well-publicised mortality associated with the programme. Given that many opiate-dependent patients say that they would like to escape from their dependence, 41 we hope that the increasing evidence-base for NTX implants will soon increase patient choice.…”

Section: Ideological Aspects Of Treatment With Ntx Implantsmentioning

confidence: 99%

Últimos desarrollos en los implantes y las inyecciones depot de naltrexona; el jovencito de la escalera se está haciendo mayor

Brewer¹,

Streel²

2010

Adicciones

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Implants and depot injections (DI) of naltrexone (NTX) have undergone considerable development since the first commercially available implants appeared in the mid-1990s. In particular, long-acting implants that can deliver relapse-preventing serum NTX levels for around six months have now been subjected to classic randomised controlled trials that have given positive and generally significant results when compared with oral NTX and placebo implants, or with standard post-detoxification care. They also provide lower serum levels that can prevent opiate overdose for several additional months and 3-year mortality rates are similar to those of methadone maintenance treatment (MMT). At least 18 months of antagonist-assisted abstinence may be desirable to normalise new, opiatefree cognitive-behavioural habits and extinguish old, maladaptive ones. We discuss ideological antagonisms between protagonists of MMT and of NTX implants, notably in Australia, but we argue that both treatments can and should co-exist. The main obstacle to the expansion of longacting implant treatment is not the lack of an evidential or theoretical base but the lack of a licensed product. NTX appears to block all opiates if serum levels are adequate and we stress its apparent lack of clinically significant hepatotoxicity. Some patients may need above-average serum levels and occasionally, habitual injectors continue to inject opiates despite experiencing no opiate effects. RESUMEN ABSTRACTLos implantes y las inyecciones depot (ID) de naltrexona (NTX) han experimentado un notable desarrollo desde que aparecieron los primeros implantes comerciales a mediados de los noventa. Específicamente los implantes de larga duración, capaces de proporcionar NTX en suero con niveles capaces de prevenir las recaídas durante unos 6 meses, han sido sometidos recientemente a las clásicas pruebas con control, con resultados positivos y, generalmente, significativamente superiores a la NTX oral o implantes de placebo o tratamientos estándar post desintoxicación. Además proporcionan niveles en sangre suficientes durante varios meses más para prevenir sobredosis por opiáceos. Por otro lado los índices de mortalidad a tres años son similares a los que están en programas de mantenimiento con metadona (PMM). Por lo menos serán necesarios 18 meses de abstinencia con el apoyo de antagonistas para normalizar los nuevos hábitos de comportamiento sin opiáceos y extinguir los viejos hábitos perjudiciales. Se discuten los antagonismos ideológicos que se dan, sobre todo en Australia, entre los protagonistas de PMM y los de implantes de NTX, concluyendo que ambos tipos pueden y deben coexistir. El principal obstáculo para la expansión de los tratamientos con implantes de larga duración no sería pues la falta de evidencia o de base teórica, sino la inexistencia de un fármaco con licencia. NTX parece que bloquea todos los opiáceos si sus niveles en suero son los adecuados; por otro lado debemos tener en cuenta su aparente falta de hepatotoxicidad. Algunos pacientes pueden necesita...

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“…This marketing frequently appeals to the desire for rapid, successful treatment in patients who have otherwise been unable to abstain. 15 The success of ROD and UROD therapy is debatable. While all studies suggest that the detoxification procedure is physiologically successful as measured by the response to antagonist challenge, recidivism ranges from 10% to 50%.…”

Section: 10mentioning

confidence: 99%

Complications of Ultrarapid Opioid Detoxification with Subcutaneous Naltrexone Pellets

et al. 2002

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Abstract. Rapid and ultrarapid opioid detoxification (ROD and UROD) centers promise quick, painless, same-day detoxification treatment for patients with opioid addiction. The goal of ROD and UROD is to provide a rapid transition from opioid dependency to oral naltrexone therapy. The patient is given general anesthesia and high-dose opioid antagonists. This induces a severe withdrawal but spares the patient the experience. In theory, the process is complete within four to five hours. The patient awakens without opioid dependency and is started on oral naltrexone. Any subsequent, persistent withdrawal symptoms are treated symptomatically. A novel, unapproved approach is to compound a pellet of naltrexone and implant it in the subcutaneous tissue. In theory, this should result in continuous therapeutic levels for this drug, and avoid issues with noncompliance. Case series: This article reports six cases of complications from the same detoxification center that performed UROD with naltrexone pellet implantation, including pulmonary edema, prolonged withdrawal, drug toxicity, withdrawal from cross-addiction to alcohol and benzodiazepines, variceal rupture, aspiration pneumonia, and death. Conclusions: The risks of this procedure are great and further studies should assess its safety and the novel use of naltrexone. Key words: opioids; heroin; addiction; detoxification; rapid detoxification; ultrarapid detoxification; naltrexone. ACADEMIC EMERGENCY MEDICINE 2002; 9:63-68 P ATIENTS with opioid addiction often struggle to achieve detoxification. Discontinuation of opioid use results in the severe discomfort of withdrawal. Many find methadone maintenance undesirable. For these patients, rapid and ultrarapid opioid detoxification (ROD and UROD) centers promise quick, painless, same-day detoxification treatment for patients with opioid addiction. This allows rapid transition from opioid dependency to oral naltrexone therapy. General anesthesia is given via endotracheal tube as well as highdose opioid antagonists. The induced withdrawal is complete within four to five hours and the patient awakens without opioid dependency. The patient is then started on oral naltrexone and any subsequent, persistent withdrawal symptoms are treated symptomatically. A novel, unapproved approach is to compound a pellet of naltrexone and

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Unethical promotion of rapid opiate detoxification under anaesthesia (RODA)

Cited by 16 publications

References 4 publications

A ‘Miracle Cure’ Misunderstood

A ‘Miracle Cure’ Misunderstood

Últimos desarrollos en los implantes y las inyecciones depot de naltrexona; el jovencito de la escalera se está haciendo mayor

Complications of Ultrarapid Opioid Detoxification with Subcutaneous Naltrexone Pellets

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